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Class III Malocclusion, Anterior Crossbite and Missing Mandibular First Molars: Bite Turbos and Space Closure to Protract Lower Second Molars

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Class III Malocclusion, Anterior Crossbite and Missing Mandibular First Molars: Bite Turbos and Space Closure to Protract Lower Second Molars JDO 56 CASE REPORT Class III Malocclusion Treated with Mandibular First Molar Substitution JDO 56 Class III Malocclusion, Anterior Crossbite and Missing Mandibular First Molars: Bite Turbos and Space Closure to Protract Lower Second Molars Abstract Diagnosis: A 32-year-old female presented with a long face (55%), maxillary retrusion (SNA 79.5º), mandibular protrusion (SNB 82.5º), retruded lips (-4.0/-3.5mm), relative lower lip protrusion, missing lower first molars (LR6, LL6), atrophic edentulous spaces, Class III buccal segments, and anterior crossbite. The Discrepancy Index (DI) was 25. Etiology: Early loss of L6s was probably due to molar-incisal hypomineralization (MIH). Anterior crossbite is a common functional compensation after lower second deciduous molars are lost at about age 12yr. Treatment: A passive self-ligating (PSL) appliance, posterior bite turbos, early light short Class III elastics were used to correct the anterior crossbite. The L6 extraction sites were closed with primarily Class II elastics. Active treatment time was 20 months. Results: Closure of the atrophic L6 sites was achieved by retracting the anterior segment and protracting lower molars. No significant root resorption nor periodontal problems were noted. The patient was pleased with treatment: excellent occlusal function, improved dentofacial esthetics, and an attractive smile arc. Clinical outcomes were a cast-radiograph evaluation (CRE) of 21 and a Pink & White (P&W) dental esthetic score of 3. Conclusions: Severe skeletal malocclusion was corrected in 20 months with a full-fixed PSL appliance, posterior bite turbos, intermaxillary elastics, and space closure mechanics. (J Digital Orthod 2019;56:48-63) Key words: Missing first molar, mesially tipped molar, atrophic edentulous ridge, anterior crossbite, passive self-ligating brackets, Class III elastics Introduction Many patients with a skeletal Class III malocclusion view surgery as the only viable option. However, that is an over treatment for patients with a good profile, near Class I molar relationship, and/or an anterior functional shift. It is essential to consider the etiology and differentially diagnose the malocclusion before formulating a treatment plan. If a centric relation (CR) to centric occlusion (CO) discrepancy exists, the problem is best 1 classified as a pseudo Class III malocclusion. Pseudo Class III patients who have an orthognathic profile in RC usually have a good prognosis for conservative treatment. 48 JDO 56 CASE REPORT Class III Malocclusion Treated with Mandibular First Molar Substitution JDO 56 Dr. Ashley Huang, Lecturer, Beethoven Orthodontic Course (Left) Dr. Angle Lee, Editor, Journal of Digital Orthodontics (Center left) Dr. Chris H. Chang, President, Beethoven Orthodontic Center Publisher, Journal of Digital Orthodontics (Center Right) Dr. W. Eugene Roberts, Editor-in-chief, Journal of Digital Orthodontics (Right) █ Fig. 1: Pre-treatment facial and intraoral photographs in CO █ Fig. 2 : Functional assessment of mandible movement: intraoral photographs in CR 49 JDO 56 CASE REPORT Class III Malocclusion Treated with Mandibular First Molar Substitution JDO 56 Diagnosis and Etiology evaluation confirmed the skeletal Class III (ANB -3˚) as previously described (Fig. 4; Table 1), but the A 32-year-old woman sought orthodontic evaluation excessive SNB angle was partially due to the C -C for missing teeth, poor dentofacial esthetics, and O R discrepancy. The TMJ radiographs (Fig. 6) showed a protrusive lower lip (Figs. 1-3). Radiographic symmetric unremarkable morphology and there examination included a lateral cephalometric film, were no signs or symptoms of TMJ dysfunction. The panoramic radiograph, and a temporomandibular American Board of Orthodontics (ABO) discrepancy (TMJ) joint series (Figs. 4-6). Cephalometric analysis index (DI) was 25 points,5 as shown in the worksheet revealed a long face, retrusive maxilla, and protrusive at the end of this report. mandible (Table 1). No contributing medical history was reported, but isolated loss of permanent first molars is usually due to a medically-related dental Treatment Objectives developmental problem in the toddler years: molar- 2 The treatment objectives were: (1) extract the incisor hypomineralization (MIH). In adults, closing hopeless lower left first molar residual root; (2) edentulous L6 spaces is challenging because of associated malocclusion, atrophic knife-edge ridge, and anchorage requirements.3-5 An anterior CEPHALOMETRIC SUMMARY crossbite may be associated with MIH, but it can be SKELETAL ANALYSIS a fortunate occurrence that increases anchorage for PRE-Tx POST-Tx DIFF. L7 protraction.3 SNA˚ (82º) 79.5˚ 79.5˚ 0˚ SNB˚ (80º) 82.5˚ 83˚ 0.5˚ Facial evaluation showed symmetrical structures, ANB˚ (2º) -3˚ -2.5˚ 0.5˚ a concave profile, retrusive lips to the E-Line, but a SN-MP˚ (32º) 35˚ 36˚ 1˚ relative protrusion of the lower lip. An unattractive FMA˚ (25º) 27˚ 28.5˚ 1.5˚ reverse smile arc was evident while smiling. The DENTAL ANALYSIS panoramic radiograph (Fig. 5) reveled missing U1 To NA mm (4 mm) 2 mm 2.5 mm 0.5 mm L6s and U8s bilaterally, retained root tip in the U1 To SN˚ (110º) 103˚ 106˚ 3˚ LR6 area, and mesial tipping of the L7s. Intraoral L1 To NB mm (4 mm) 0 mm -1 mm 1 mm examination showed missing teeth (UR8, UL8, LR6, L1 To MP˚ (90º) 77˚ 72˚ 5˚ and LL6), residual root tip in the area of the LL6, FACIAL ANALYSIS anterior crossbite of all four maxillary incisors, E-LINE UL (-1 mm) -4 mm -4 mm 0 mm buccal crossbite of the UL7, maxillary dental midline E-LINE LL (0 mm) -3.5 mm -1.5 mm 2 mm coincident with the facial midline, mandibular dental %FH: Na-ANS-Gn (53%) 55% 55.2% 0.2% midline 1mm to the left, and a C -C discrepancy O R Convexity: G-Sn-Pg’ (anterior functional shift) from an initial edge-to-edge (13º) 2˚ 1.5˚ 0.5° position (Figs. 1-3). Pre-treatment cephalometric ██ Table 1: Cephalometric summary 50 JDO 56 CASE REPORT Class III Malocclusion Treated with Mandibular First Molar Substitution JDO 56 █ Fig. 6: Pre-treatment TMJ radiographic series from left to right are: closed right, open right, closed left, and open left. correct the anterior crossbite by opening the bite and retracting the lower anterior segment, (3) █ Fig. 3: Pre-treatment dental models (casts) protract the mandibular molars to close space, and (4) correct the maxillary anterior smile arc. Treatment Alternatives Uprighting the L7s and leaving the space for implant-supported crowns was considered. That option may decrease treatment time, but it was more expensive and invasive. Also, the buccolingual width of the atrophic edentulous ridges required augmentation bone grafts. After carefully considering the pros and cons for each option, the patient selected orthodontic space closure. █ Fig. 4: Pre-treatment lateral cephalometric radiograph Treatment Progress The patient was referred for removal of the residual LL6 root, and one month later, Damon Q® passive self-ligating (PSL) 0.022-in brackets (Ormco, Glendora, CA) were bonded on all permanent teeth. All elastics, archwires and auxiliaries were produced by the same manufacturer. Standard torque brackets were used on all teeth except: 1. low torque brackets █ Fig. 5: Pre-treatment panoramic radiograph on the maxillary incisors, 2. low torque brackets 51 JDO 56 CASE REPORT Class III Malocclusion Treated with Mandibular First Molar Substitution JDO 56 bonded up-side-down (to express high torque) on were effective for unlocking the interdigitation the mandibular incisors, and 3. high torque brackets and facilitating overjet and overbite correction. In on L3s. Archwire materials were copper nickel- the 4th month of treatment, a positive overjet was titanium (CuNiTi), titanium molybdenum alloy achieved and the bite turbos were removed (Fig. 8). (TMA), and stainless steel (SS). The maxillary archwire To enhance space closure efficiency and to control sequence was: 0.014-in CuNiTi, 0.014x0.025-in iatrogenic rotation, four lingual buttons were CuNiTi, 0.017x0.025-in TMA, and 0.016x0.025-in SS. bonded on the lower first premolars and the second The corresponding lower arch sequence was 0.014- molars. A sequence of 0.016x0.025-in Pre-Q NiTi and in CuNiTi, 0.014x0.025-in CuNiTi, 0.016x0.025-in 0.019x0.025-in Pre-Q NiTi wires were installed in the pre-Q NiTi (20º of lingual root torque in the anterior lower arch in the 4th and 6th months respectively, segment), 0.019x0.025-in pre-Q NiTi, and 0.016x0.025- to increase incisors torque. In the 8th month, Class in SS. In the first month of active treatment, posterior II elastics (Bear 1/4-in, 4.5-oz) were applied bilaterally bite turbos were constructed with Fuji II type II from the maxillary canines to the mandibular 2nd glass ionomer cement (GC America, Alsip IL) on the molars for 3 months to complete the A-P correction occlusal surfaces of the mandibular second molars. and promote smile arc development (Fig. 9). Fifteen The patient was instructed to wear the short Class III degree root lingual third order bends in 0.016x0.025- elastics (Quail 3/16-in, 2oz) from the upper first molars in SS archwires were applied to mandibular incisors to the lower first premolars bilaterally, to correct in the 9th month and to the maxillary incisors in the anterior crossbite (Fig. 7). Bilateral bite turbos the 15th month (Figs. 10 and 11). In the 12th month, 1M █ Fig. 7: In the 1st month of the treatment, the 0.014-in CuNiTi archwires engaged in all dentition of both arches. The anterior crossbite was corrected with bite turbos (blue circles), alignment of the maxillary anterior segment, and 2-oz Class III elastics (blue lines). Class III elastics provide horizontal and vertical forces to facilitate early correction of anterior crossbite. 52 JDO 56 CASE REPORT Class III Malocclusion Treated with Mandibular First Molar Substitution JDO 56 4M █ Fig.
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